A 'stinger' in Rugby: a transient episode or something more sinister?
A 22-year-old male amateur rugby union player misplaced his shoulder in a tackle during the final quarter of a game resulting in his head being laterally forced away from his dominant tackling shoulder causing a stretch of the brachial nerve in the neck, defined as being a 'brachial neuropraxia' or 'stinger' injury.
Approaching the player on the pitch, it was clear that he was in distress. He was crouched on the ground, clutching his arm, with a slouched appearance and making a moaning sound. A quick c-spine and concussion assessment cleared any cervical or head injury. However, the symptoms of radiating burning pain down the arm, pins and needles in the arm and hand as well as muscular weakness in the affected bicep indicated that the player needed to be removed from the field for further assessment.
Based on the reported symptoms, the player was assessed for a 'stinger' a very common contact injury in rugby union. Generally, the effects of a 'stinger' are of a transient nature and resolve within a couple of minutes On this occasion though, they remained, resulting in the player failing the stinger specific return to play criteria (RTP).
Following assessment after the game, the player's symptoms had disappeared and he was advised to rest the shoulder and seek medical advice if the symptoms reoccurred. Upon reporting for training a few days later, he reported that his symptoms had returned the evening after the game and that he had been unable to functionally use his arm. This had led to an absence from work for the player, which, more than 72 hours after the incident was a real concern.
On questioning the player, it transpired that he had already experienced a stinger 3 times in the season prior to this incident, but these hadn't been reported to the therapist. The player explained that, because the symptoms had disappeared within a few minutes of occurrence, he didn't feel it necessary to report adding that he felt there was no severity to the injury and it did not affect his play.
The player was advised to visit his GP, who referred him for an imaging scan (X-ray and MRI) of the neck and shoulder. Further exploration revealed that the repeated trauma of the neck and shoulder had resulted in a narrowing of the neuroforamen in the c-spine due to swelling, resulting in an entrapment of the brachial nerve root. This caused the symptoms to persist for a longer period of time and to return without any characteristic trauma. Due to the severity of the condition, the player was advised to retire for the rest of the season, avoid strenuous physical activity of the shoulder, and be placed through a shoulder specific therapeutic treatment and rehabilitation programme.
This case study highlights that first observations of an insignificant injury can materialise to be something more sinister if not managed effectively. It is apparent through exploration of research surrounding this issue that there is a common view among rugby players that the significance for this type of injury is low, resulting in the underreporting of such occurrences. It is therefore crucial that players and coaches are educated on this type of injury, and encouraged to report incidents so that they can be managed effectively.
For a further insight into the 'Management of Stingers in Rugby Players' please attend the Sports Therapy Association (STA) conference session on Wednesday 22nd November 2017 at 3.30pm-4.00pm.